Miniaturized hemodynamic transesophageal echocardiogram (hTEE) can accurately diagnose pericardial tamponade after open-heart surgery Shreya Gupta, BS Joseph Miessau, MS; Harrison Pitcher, MD; Qiong Yang, MD; Nicholas Cavarocchi, MD; Hitoshi Hirose, MD. Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Introduction Cardiac tamponade in early priod of post cardiac surgery is a difficult and critical diagnosis Hemodynamic Transesophageal Echocardiography (hTEE) is a point of care device Emergent assessment and intervention is necessary to decrease mortality and morbidity Negative exploration is not benign and may have worse outcomes

What is hTEE? Hemodynamic Trans-Esophageal Echocardiography Miniaturized TEE probe Non-invasive (5mm) Real time monitoring Keep in place max 72h Allows visualization of cardiac function Provides information on fluid status, ventricular function This is a minitaurized TEE probe almost the size of an NG tube. It is non invasive real time monitoring providing us hemodynamic information, functioning of the Left and right ventricles.

Objective/ Methods We investigated retrospectively whether hTEE could give information to diagnose post cardiotomy tamponade Study period: May 2011 to July 2013 Total number of hTEE studies to r/o tamponade: 21 patients 17 males, 4 females Average age of 60.7 years We did a retrospective review of hTEE studies done on patients to rule out pericardial tamponade in early post-op period- 72h. The study period was from May 2011- to july 2013 . The primary procedure on these patients were CABG +- valve, transplant, VAD and dissections. 21 patients underwent hTEE study with the clinical suspicion of post-cardiotomy tamponade.

Clinical suspicion of tamponade (n=21) Negative study n=9 Small hematoma n=2 Positive study n=10 Chest tube n=1 Emergent OR n=8 Coagulopathy n=1 hTEE observation hTEE observation hTEE observation Stable size Improved effusion Worsen clot For 18 unexplained hemodynamic instability followed by hTEE study, and 3 had unexplainable High CT draniage followed by hTEE studies to rule out tamponade. All of these patients were in cardiogenic shock [on four inotropes and or pressors with an average CI of 2. and CT output of avg 100ml/h- PA diastolic of 18-19 and CVP of 12-13] 8 went for immediate OR explorations – which were all positive with 100% survival rate. One of patient had an tamponade that was managed by milking the CT- confirmatory hTEE showed marked hemodynamic improvement. Another patient, had extensive coagulopathy that was first managed medically and subsequently taken to the OR for a positive exploration. 2 patients had small hematomas without ventricular compression and repeated hTEE study showed no increase in size and hence OR exploration. 9 patients had a negative hTEE studies. None of these patients were taken to the OR for any explorations. These were dx with hypovolemia (5), RV failure (2) and BiV failure (2). OR exp OR finding of tamponade: all No OR explorations No OR explorations No OR explorations

Conclusions Miniaturized hTEE is an efficient tool that can diagnose early post-cardiotomy pericardial tamponade May be able to reduce resources – both time and finance- by using hTEE in the intensive unit setting Our retrospective study showed that hTEE is an efficient tool that can allow us to diagnose early pericardial tamponade in post-cardiotomy patients in timely fashion in conjunction with conventional monitoring. With hTEE, which is available in the intensive care unit and performed by intensivitists, we may reduce resource utilization.